This report by California Healthcare Foundation reports how smartphone are changing how doctors are using smartphones and other mobile devices to improve patient care. And how they fit in with HIPAA and HIT regulations.

1. C A L I FOR N I A
H EALTH C ARE
F OU NDATION
How Smartphones Are
Changing Health Care for
Consumers and Providers
April 2010

2. How Smartphones Are
Changing Health Care for
Consumers and Providers
Prepared for
California HealtHCare foundation
by
Jane Sarasohn-Kahn, M.A., M.H.S.A.
April 2010

3. About the Author
Jane Sarasohn-Kahn, M.A., M.H.S.A., is a principal with THINK-
Health and writes the Health Populi blog.
Note: Inclusion of products and vendors in this report does not
constitute an endorsement or recommendation.
Acknowledgments
The author expresses special thanks to the experts who provided
counsel, data, and insights that are incorporated into this report:
Meredith Abreu-Ressi, Manhattan Research; Andre Blackman, Pulse +
Signal; Ed Daniels, Point-of-Care Partners; Scott Eising, Mayo Clinic;
Dr. B.J. Fogg, Stanford, Persuasive Technology Lab; Susannah Fox,
Pew Internet & American Life Project; Katy Hartley, Phillips Center
for Healthy Living; Rob Havasy, Center for Connected Health; Raj
Kapoor, Advance Wellness Institute; Dr, Joseph Kim, Physician and
Technologist, Medical Smartphones blog; David Krajicek, GfK;
Monique Levy, Manhattan Research; Joy Liuzzo, Insight Express; Julie
Murchinson, Health 2.0 Accelerator; David Sanderson, MedApps;
Brett Shamosh, WellApps; Juhan Sonin, MIT; Jonathan Woodbridge,
UCLA; and Marion Zabinski, Myca. Two generous peer reviewers
have added valuable input into the paper: Dr. Ted Eytan, The
Permanente Federation, LLC; and Brian Dolan, MobiHealthNews.
About the Foundation
The California HealthCare Foundation is an independent
philanthropy committed to improving the way health care is
delivered and financed in California. By promoting innovations in
care and broader access to information, our goal is to ensure that all
Californians can get the care they need, when they need it, at a price
they can afford. For more information, visit www.chcf.org.
©2010 California HealthCare Foundation

4. Contents
2 I. Smartphones Meet Health and Health Care
5 II. Who Are the Consumers of Mobile Internet?
8 III. Smartphone Apps for Clinicians and Consumers
Medical Reference Tools
Diagnostic Tools
Continuing Medical Education
Patient Records — EHRs and PHRs
Patient and Health Consumer Support
13 IV. The Market for Smartphones and Health:
Some Barriers
17 V. Looking Forward: Insights from the Early
Adoption Phase
19 Endnotes

5. I. Smartphones Meet Health and Health Care
The new wellness delivery channel tHe topiC of smartpHones in HealtH is an interseCtion
of two fast-evolving ecosystems: health and technology. The junction
for ubiquitous care will be the
is a dynamic one in which a particular communications platform is
smartphone, and it will happen advancing both consumers’ and providers’ engagement with health
information technology.
sooner than you think.
The speed of the uptake has been remarkable for a nation that has
— JOHN MATTISON, M.D.
KAISER PERMANENTE been traditionally slow to adopt HIT, as Figure 1 shows. Two-thirds
of physicians used smartphones in 2009. About 6 percent of these
were using a fully functional electronic medical record or electronic
health record system — while only 1.5 percent of hospitals had a
comprehensive electronic health record system as of 2008.1
On the consumer side, 42 percent of Americans owned
smartphones as of December 2009, despite the recession that began
a year earlier.2 In fact, according to cnet, the smartphone market was
“unfazed by the recession.”3
What is it about the smartphone that makes it so attractive to
consumers and providers of health care? 4 Unlike any other HIT
platform, the smartphone is basically an inexpensive handheld
Figure 1. Consumer Smartphone Ownership, October 2006 to
December 2009
45% 42%
40%
35%
30%
25%
20%
15%
15%
10%
5%
0%
Oct Jan Apr Jul Oct Jan Mar Jun Sep Dec Mar Jun Sep Dec
’06 ’07 ’07 ’07 ’07 ’08 ’08 ’08 ’08 ’08 ’09 ’09 ’09 ’09
Source: “New Survey Shows Android OS Roiling the Smart Phone Market,” ChangeWave Research, January 2010.
2 | C alifornia H ealtH C are f oundation

6. computer that enables users to accomplish tasks
anywhere, anytime. It is so intuitive and user-friendly Smart and Smarter
In the absence of an industry-wide definition of
that most people can download and use the many
“smartphone,” the boundaries between types
available applications — or apps — without any of phones are blurring. Here are some general
training or special knowledge about computers. understandings:
For clinicians, the smartphone offers an • Cell phones/mobile phones run over wireless
alternative to many health IT formats that have communication networks through radio waves or
been cumbersome and costly to adopt, and that satellite transmissions. All cell phones provide voice
communications and texting via Short Message
may interrupt their workflow. As of February
Service, or SMS.
2010, there were 5,805 health, medical, and fitness
• Feature phone or full-feature phones have
applications within the Apple AppStore. Of these, additional functions such as a camera, mp3 player,
73 percent were intended for use by consumer or or downloadable games that are available through
patient end-users, while 27 percent were targeted the wireless provider.
to health care professionals. It should be noted • PDA phones or personal digital assistants
that, although developers usually have a principal combine cell phone, Web browsing, and organizer
functions such as calendars.
audience in mind, all users can and do download
• Smartphones run on a specific operating system
the apps.5 In the “medical” category, 33 percent of
(OS) and allow download of apps that run on the
apps are meant for consumers/patients, 32 percent OS. Major operating systems include iPhone OS,
for physicians, 17 percent for medical students, BlackBerry OS, Windows Mobile, PalmOS, WebOS,
4 percent for other health professionals, and Symbian, and all types of Linux including Android.
2 percent for nurses (10 percent were miscategorized
by MobiHealthNews’ definition).
Figure 2. Medical iPhone Apps Geared to Consumers, Physicians, Medical Students, 2010
Other
12%
Miscategorized
CME (1%) 12%
Medical
Medication Adherance (1%) Reference
Emergency Information (2%) 50%
Chronic Disease (3%)
Prenatal and Infant Care (3%)
EMR and Operations (7%)
Calculator
9%
Source: “The World of Health and Medical Apps,” MobiHealthNews 2010 Report, February 2010.
How Smartphones Are Changing Health Care for Consumers and Providers | 3

7. Within “medical reference apps,” the largest mobile health consumer, we found that people are
category is medical student study guides (19 percent), looking for very action-oriented information. They
followed by clinical consult (9 percent), anatomy are not necessarily going to do in-depth research
(7 percent), and drug reference (7 percent). Within via mobile. If that’s the case, they will take content
the consumer-focused health and fitness apps, the directly from the Web site. So we’re asking: How do
most popular category is cardio exercise (15 percent), we create applications for the mobile form factor and
followed by stress management (12 percent), diet platform, and provide action-oriented information?”
(11 percent), and strength training (6 percent). See For those providers already connecting with
Figures 2 and 3. patients through electronic health records and
While Apple and the iPhone are the leading personal health records, the stage is set for mobile
source of health and medical apps for smartphones health, whether on smartphone or feature phone.
in 2010, more apps are being developed for other Kaiser Permanente’s personal health record, My
operating systems that have or plan to serve both Health Manager, has a user base of over 3 million
health consumers and physicians. enrollees. It would be a relatively easy transition to
In 2010, most health consumers regularly seek morph over to mobile phones.
health information online through trusted portals Kaiser can capitalize on its investment in
such as Mayoclinic.com, which has provided health electronic health records and personal health
content online since 1995 to “empower people to records — EHRs/PHRs — and develop mobile apps
manage their health.” Mayo has now gone mobile. to serve patients managing chronic conditions as well
“We’re a very content-oriented organization,” said as help healthy enrollees stay that way.
Scott Eising of Mayo Clinic. “In our research into the
Figure 3. Medical Reference iPhone Apps, 2010
Student
Other Study Guides
Dentist (1%) 21% 19%
Reference Codes (1%)
Radiology (1%)
Clinical Consult
Veterinarian (2%) 10%
Swine Flu/H1N1 (2%)
Nurse (3%) Anatomy
7%
Medical Dictionary (4%)
General Patient (4%)
Drug Reference (7%)
Home Remedies (5%)
Literature (6%)
Emergency Care (5%)
Source: “The World of Health and Medical Apps,” MobiHealthNews 2010 Report, February 2010.
4 | C alifornia H ealtH C are f oundation

8. II. Who Are the Consumers of Mobile Internet?
s martpHones are taking a prominent SMS (text messaging) as they were to make voice
place among the mobile phones that are used to calls from their mobile phone.7
reach the Internet. Eighty percent of Americans had
a cell phone, a PDA phone, or a smartphone as of
The Marrying Kind
December 2009, and one-third of people have used a
In Texting for Health, B.J. Fogg of Stanford Persuasive
cell phone or smartphone to access the Internet. The Technology Lab observed: “In some ways, we don’t
number of mobile Internet users increased 74 percent merely adopt mobile devices; we marry them. We
between 2007 and 2009.6 See Figure 4. usually spend more time with our mobile phones than
with our spouses or partners…. The best interactions
in a marriage will create feelings of trust, competence,
Figure 4. Internet Use on a Mobile Device, 2007 vs. 2009 and delight.”
• Yesterday • Ever
A consumer segment named techfluentials has
32%
been identified by the market research firm GfK.
“Techfluentials see technologies as extensions
24% of themselves, especially in today’s social media
environment,” David Krajicek of GfK explained.
19%
“These individuals see those tools as coming to be
parts of their lives. Over time, techfluentials will be
11% the next wave of individuals that will become more
focused on health as issues and problems arise. They
2007 2009
will turn to the tools they’re using in other parts of
Source: Wireless Internet Use, Pew Internet & American Life Project, July 2009.
their lives” to manage their health, said Krajicek.
While accessing the Internet via stationary
computers is stratified by socioeconomic status,
Research by Wells Fargo, the financial services mobile search is not. African Americans are the most
company, found that the “most digital” age cohort active users of the mobile Internet — and their use of
is people in their thirties. And while the bulk of it is also growing the fastest. This means the digital
younger people have integrated online and mobile divide diminishes when mobile use is taken into
technologies into their daily lives, older people are account. See Figure 5 on the following page.
doing so as well. Although 59 percent of adults Twenty-nine percent of African Americans
over 70 responded that they do not use any online use the Internet on their handheld on an average
entertainment technologies — that means that day, significantly greater than the national average
41 percent do. Furthermore, 60 percent of people of 19 percent.8 Looking across a range of digital
age 45 and over were found to be just as likely to use activities (some done online using a computer and
How Smartphones Are Changing Health Care for Consumers and Providers | 5

9. Figure 5. Americans Accessing Internet by Tethered Table 1. Wireless Internet Use,
or Cell Phone Means, by Race, 2009 by Selected Characteristics, 2009
% o F To TAl
Total Adults 55%
94% Men 59%
91%
87%
Women 51%
Race/Ethnicity
White 52%
African American 59%
Hispanic 62%
Age Group
18 to 29 80%
30 to 49 66%
White African American Hispanic
50 to 64 42%
Source: Wireless Internet Use, Pew Internet & American Life Project, July 2009. 65+ 16%
Annual Household Income
Less than $30,000 46%
others on a mobile device) African Americans and $30,000 to $49,999 55%
Whites, on average, have the same level of usage. $50,000 to $74,999 61%
The high level of activity among African
$75,000 and higher 76%
Americans on mobile devices helps offset lower levels
Educational Attainment
of access to tools that have been traditional onramps
Less than high school 41%
to the Internet — desktop computers, laptops, and
High school 42%
home broadband connections. Still, there remain
Some college 63%
disparities between mobile users of the Internet and
those who have tethered access. People in rural areas, College and higher 69%
as well as those who have less education or are over Community Type
age 65, are less likely to have wireless Internet access. Urban 57%
See Table 1. Suburban 56%
Rural 45%
Source: Internet User Profiles Reloaded, Pew Internet & American Life
Project, January 2010.
6 | C alifornia H ealtH C are f oundation

10. Mobile health was named by Gartner as one of However, there is still a gap between the promise
its top ten consumer mobile applications for 2012. and the reality for health consumers who are ill.
Mobile health monitoring could help payers, both As the chart illustrates, people with two or more
private and public, to reduce costs related to chronic chronic conditions are least likely to go online, have
diseases and improve patients’ quality of life. Gartner broadband at home, or receive text messages. See
sees that the industry will be able to monetize Figure 6.
mobile health services by offering mobile health care The opportunity here for developers is that
monitoring products, services, and solutions to care 70 percent of people with two or more chronic
delivery organizations.9 conditions have a cell phone.
Figure 6. Technology Use by People with Chronic Conditions, 2008
Go online
81%
68%
52%
Dial-up at home
12% • No Condition
16% • 1 Condition
15% • 2+ Conditions
Broadband at home
61%
45%
37%
Wireless access
50%
31%
24%
Have a cell phone
89%
76%
70%
Get all or almost all calls on cell phone
21%
9%
11%
Send/receive text messages
60%
32%
23%
Source: Chronic Disease and the Internet, Pew Internet & American Life Project, March 2010.
How Smartphones Are Changing Health Care for Consumers and Providers | 7

11. III. Smartphone Apps for Clinicians
and Consumers
a CCording to m anHattan r esearCH , “Many doctors are behind the times in practicing
the number of physicians who own smartphones will medicine. They’re applying old guidelines to care,”
increase from 64 percent in 2009 to 81 percent by said Dr. Kim. The best way to keep up to date is not
2012. An Epocrates survey of its users — published by attending a symposium once a year or checking
ten days after Apple’s announcement of the iPad in emails, he said. “If you give clinicians the right tools
February 2010 — found that one in five physicians and the right information at the right time, it will
said they were likely to purchase an iPad.10 improve the way they treat patients.” An example
Some of the most widely used mobile applications is FDA Recalls, a free app on iTunes that provides
by physicians are drug and clinical references, and information about recalled products.
clinical tools such as dosage calculators.11 Monique Medical Reference. Because clinical care is
Levy, senior director of research for Manhattan information-intensive, it is natural for health
Research, said she is seeing the line between the tasks information to go mobile as clinicians make decisions
done by physicians on desktop computers and on at the point of care. Among the most mature mobile
mobile devices “start to blur.” Transaction-oriented reference sources developed for smartphones is
point-of-care apps, such as electronic prescribing Epocrates, an online medical reference company
and evidence-based decision support, are the next that celebrated its 10th anniversary in 2009.
growing category for physicians’ smartphones. Epocrates offers mobile platforms for the major
Following are a few examples of health and operating systems including Android, Blackberry,
medical app categories. The actual market includes iPhone, Palm, and Win Mobile. More than
many more, and is growing rapidly. 125,000 physicians use Epocrates’ products on
iPhone and iPod touch devices, alone. The first
Medical Reference Tools medical application for the iPhone, Epocrates’
Alerts and Awareness. Dr. Joseph Kim, physician drug reference, is the most popular free medical
technology blogger at Medical Smart Phones, sees download in the iTunes store. A study at Brigham &
opportunities for helping physicians stay abreast Women’s Hospital in Boston found that 60 percent
of clinical information. “Everyone has a spare five of Epocrates users reported avoiding three or more
minutes in the day,” he said. “The question is, are medical errors a month.12 The company’s own time-
doctors using their smartphones to stay current on study found that doctors who use the reference tool
breakthroughs and FDA alerts?” Smartphones can be save at least 20 minutes a day in pharmacy call-backs
networked into alert systems via Twitter and other and real-time mobile information search while in the
platforms. The FDA or CDC could issue alerts to exam room.
virtually every health provider via the clinician’s Another major medical reference firm, Skyscape,
handheld, setting off an alarm. Clinical advice, works with more than 50 health publishers and has
guidelines, and news on the latest breakthroughs assembled the largest library of medical resources
could be communicated this way in five-minute bits. available for every smartphone operating system.
8 | C alifornia H ealtH C are f oundation

12. Anatomy references include Netter’s Anatomy results and providing diagnostic support. Current
app, which is based on the popular Atlas of Human popular lab apps include ARUP Consult and
Anatomy. The Medical Encyclopedia by University of Care360.
Maryland Medical System was one of the ten most Digital imaging. The OsiriX app can be
popular free apps in the iTunes Store in December thought of as a mobile PACS (picture archiving
2009. communications system) for the smartphone. At the
Like physicians, consumers also access medical 2009 annual meeting of the Radiological Society of
reference information via mobile devices. The Evincii North America (RSNA), several papers demonstrated
app helps consumers look for over-the-counter the efficacy of using smartphones in digital imaging
medication for particular symptoms. This app grew applications.15 ERoentgen Radiology Dx is an app
out of a service once available via a kiosk in retail that helps radiologists identify the most appropriate
pharmacies. There are also many symptom checkers radiology exam for a patient.
available for consumers; in 2010, the Mayo Clinic ECG. There are many electrocardiogram apps
began to offer the Symptom Checker iPhone app that offer images of the most common ECG results.
in February 2010, similar to the hospital’s online Instant ECG (one of the top ten paid iPhone apps in
version. December 2009), ECG Guide, and ECG Interpreter
are among the most used.
Diagnostic Tools Emergency department. Mobile health solutions
General diagnosis. One of the most popular apps on smartphones are designed to increase productivity
for doing differential diagnosis is Diagnosaurus, in busy ERs. Physicians use the Vigilance app to
written by Dr. Roni Zeiger (currently affiliated track patients’ vital signs, transmit live videos from
with Google Health). The IDdx is an app covering exam and operating rooms, and receive alerts when
infectious disease diagnosis, based on Control of patients are in distress so doctors can respond even
Communicable Disease Manual. Some diagnostic before nurses page them.
apps target specific conditions: STAR Analytical Obstetrics. AirStrip OB is an iPhone app that
Services developed an app that analyzes coughs.13 provides obstetricians real-time, remote access to fetal
The company received a grant to create the app for heart tracings, contraction patterns, nursing notes,
developing countries. Star’s Suzanne Smith noted and vital signs. Obstetricians can monitor different
that coughs are “the most common symptom when stages of labor even when they are not by a patient’s
a patient presents, and we are relying on doctors side. This increases the OB’s ongoing interaction
and nurses with good old technology from the 19th with the labor and delivery department and gives the
century.”14 doctor real-time data.
Lab apps. Smartphones can deliver physicians’ Remote physician consultation. Remote
laboratory and blood work results as soon as they physician consults via desktop computers have
are completed. This just-in-time reporting can help emerged through services like American Well, Myca
physicians and patients avoid phone tag. If a value Health, RelayHealth, and TelaDoc. They have
is abnormal, the physician can immediately email gained traction in the market as reimbursement is
a patient follow up instructions. The lab app will negotiated between payer, provider, and patient.
evolve next to assist clinicians in interpreting lab As this alignment of incentives continues, remote
How Smartphones Are Changing Health Care for Consumers and Providers | 9

13. consults will migrate to various devices beyond the MacPractice MD, motionPHR, NextGen, Ringful,
desktop computer and, over time, onto smartphones. and Webahn.
Qualcomm has 12,000 employees in the San Diego This list will grow “exponentially,” according to
area. The company operates a corporate health center Dr. Joseph Kim, who says, “we’ll see a huge change
and is creating “the clinic without walls,” which uses in the next couple of years. But will physicians know
the Myca platform for managing communications how to use these systems effectively? There isn’t much
between the care team and the employee. Many robust clinical decision support backed by evidence-
Qualcomm workers travel outside of San Diego; based medicine yet” for these applications.
Myca enables remote consultations between health With the implementation of the American
center staff and mobile employees via mobile devices Recovery & Reinvestment Act of 2009 (ARRA),
like smartphones, which enhances the company’s stimulus funding will be distributed to health
ability to extend wellness beyond the company’s providers who implement electronic health records
physical doors. As Dr. Marion Zabinski of Myca (EHRs) according to “meaningful use” criteria.
explained, “people are so connected to phones, Mobile EHRs could open up physician access to
they’re an extension of themselves. You can’t have patients if the apps have the same security layers as
your doctor with you all the time but the phone their desktop counterparts. Then physicians could
can keep you on the right path toward health and communicate with patients from anywhere, and not
wellness.” be tethered to the desktop application. “This could
change physician access electronically from 24 hours
Continuing Medical Education to 24 seconds,” predicted Dr. Ted Eytan of The
The Internet is playing a growing role in continuing Permanente Federation.
medical education (CME).16 Several services provide As consumers get more engaged in tracking their
CME credits using smartphones, including Epocrates health information, personal health records (PHRs)
Mobile CME, MedPageToday, QuantiaMD, will gain adoption. Four in five U.S. adults believe
ReachMD, Skyscape CME STAT, and UpToDate. that online PHRs would be beneficial in managing
Wolters Kluwer Health, the medical publisher, their health and health care. Nearly one-half of
developed the XtraCredit app that provides CME Americans are interested in using an online PHR
credit for clinical research done online. CME via service.17 However, PHR adoption remains very low;
smartphones will grow in adoption as mobile Web only 3 percent of U.S. adults had a PHR in 2008. If
browsers accommodate more multimedia formats meaningful use criteria under ARRA include patient-
such as Flash. engagement, then PHR adoption should grow.
The PHR supply side is populated with about
Patient Records — EHRs and PHRs 20 Internet-based PHRs on the market as of
This crowded market segment is attracting new February 2010.18 PHRs can be stand-alone (where
entrants who are innovating “lighter” open health data are populated by the consumer), tethered
source solutions, including records apps for to an EMR system (controlled by physicians),
smartphones. Several currently offer smartphone or non-tethered (Internet-based PHRs largely
capability, including Allscripts, CareTools iChart, controlled by consumers). Because smartphones are
eClinicalWorks, EPIC’s Haiku, LifeRecord, extensions of users’ personal lives, they could make
10 | C alifornia H ealtH C are f oundation

14. useful platforms for personal health records that are among patients with chronic conditions may be as
managed by consumers themselves. low as 20 percent.19, 20 Many factors are involved,
A handful of PHRs are available via smartphone. including cost/affordability, ineffective patient/
Polka works on the iPhone; it stores and analyzes the provider interaction, lack of patients’ understanding
consumer’s personal health data, and offers health their disease, complex treatment plans, side effects,
reminders. Aetna connects enrollees’ smartphone confusion and forgetfulness, and language barriers.21
apps to a PHR. The ICE app was developed by Technology can play an important role in
Legalzoom and Donate Life America to store users’ supporting people to adopt and stick with prescribed
personal information that can be accessed by first treatments. Medication Tracker, MedsLog and
responders (e.g., paramedics, firefighters, and ER Pillbox are among the more popular medication
workers) “in case of emergency.” In addition to trackers in the iPhone store. The Pillboxer Lite app
this app, there are several other emergency apps tracks medications, vitamins, and supplements with a
incorporating the “ICE” acronym in their names. graphic interface that resembles the “Sunday through
Saturday” pillbox format. The Pill app can remind
Patient and Health Consumer Support women to take their birth control meds. Inhaler
Scott Eising of the Mayo Clinic said, “Part of our Tracker helps asthma sufferers track and record
vision for Mayo is that it’s not only a destination inhaler use.
medical center. We are going to take care of patients The HIV/AIDS Red Ribbon Health Manager
here and ‘there,’ whether at home or at work.” app generates medication reminders via both email
Patients managing chronic conditions and healthy and text. Users can opt for one or both. The app
consumers who want to keep well can be served in a incorporates Observations of Daily Living (ODLs),
variety of ways. Mayo Clinic launched its first iPhone which enable users to track aspects of their lives that
app, Mayo Clinic Meditation, in December 2009. are germane to their conditions.
The clinic followed up this app in February 2010 For multiple sclerosis, i-inject is an app available
with the free Symptom Checker, based on its popular for iPhone that sets medication reminders, tracks
online version. rotation of injection sites, runs medication reports,
Some apps focus on a single illness. Brett and enables emailing to physicians.
Shamosh, who has ulcerative colitis (UC), created Mobile and home monitoring. A number
an iPhone app to help fellow patients deal with the of apps connect patients with chronic conditions
condition. “We developed the software to cater to to clinicians, caregivers, and health coaches on a
you and your personal condition. If you’re willing continuous basis. Sensor technologies combined with
to talk to us, you have to be incentivized, even mobile communications can be used to track various
inspired, to work with us,” Shamosh has learned. As health measurements for patients or loved ones.
he receives feedback on his GI Monitor app from Among a long list of sensors that can be incorporated
users, he continues to add user-defined value to the into smartphones and used for health monitoring are:
application.
◾◾ Accelerometers that register different motions
Medication adherence and compliance.
and walking “gait”;
Studies on patient adherence to prescribed drug
regimens have demonstrated that compliance
How Smartphones Are Changing Health Care for Consumers and Providers | 11

15. ◾◾ Infrared photo-detectors that measure body wellness, fitness, and nutrition. Examples are: The
temperature, heat flux and heart rate; and Carrot, Eat This/Not That (based on the popular diet
book), SparkPeople, and WebMD Mobile (with over
◾◾ Glucometers to measure blood glucose.
1 million iPhone downloads in 2009). Other wellness
apps are focused on complementary and alternative
People with diabetes have access to a large array
medicine, such as those offering support for sleep and
of mobile monitoring devices, some of which are
meditation like the Mayo Clinic offering.
available through smartphones. Roche Diabetes Care,
Managing conditions. A highly activated group
the maker of Accu-Chek blood glucose meters and
of health consumers has adopted mobile devices
insulin delivery systems, partners with Mylestone
to help manage chronic conditions. In early 2010,
Health’s Glucose Buddy, which integrates with
apps were available for the most common chronic
Roche’s iPhone app. The app calculates the impact of
conditions including (alphabetically) anorexia,
the user’s meals, activities, and other actions on blood
asthma, cancers, chronic obstructive pulmonary
glucose levels.
disease, Crohn’s disease, diabetes, glaucoma, heart
MedApps began as a smartphone-based
disease, HIV/AIDS, hypertension, migraine, and
monitoring application. However, given the relatively
multiple sclerosis, among other diseases. Most
small user-base of smartphones in target populations
disease-specific apps in the iTunes Store are aimed
(chronically ill people, seniors), the company
at clinicians as “medical apps,” although they can be
subsequently re-engineered its offering in the form
downloaded by anyone.
of a wireless handheld device, the HealthPAL. This
Ed Daniels, an expert on point-of-care
device looks like a wireless phone, but operates
technology, defines “symptom-driven” health apps as
differently. Patients managing chronic conditions
those where navigation is controlled by user-entered
do their regular monitoring through their usual
medical information, and where the application may
devices including blood pressure cuffs, glucometers,
be programmed to use that data to record patient
spirometers, pulse oximeters, and weight scales. The
symptoms over time, to recommend treatments, or
Bluetooth-enabled HealthPAL device communicates
to connect the user with services, physicians, and
the user’s health data to providers for their
hospitals.
monitoring, review, and reporting. The data can
Caregivers of children or aging parents might
also be routed to a health record repository such as
find smartphones useful for streamlining complicated
Microsoft HealthVault or Google.
and/or long-distance care for their loved ones. In a
Home care. Nearly 40 percent of home health
survey of parents of children with diabetes conducted
agencies use some kind of point-of-care system in the
by the Center for Connected Health, most expressed
field. Use of handhelds for home health is expected
interest in enrolling in a mobile phone glucometer
to have significant growth. One in every three
service, with two-thirds of parents feeling very
home care managers uses a smartphone. Most use a
positive about a proposed prototype. According
BlackBerry, with 50 percent of the market, followed
to the researchers, “enthusiasm decreased with
by iPhone (15 percent), Microsoft (15 percent), and
increasing annual service cost.”23
Palm Treo (6 percent).22
Wellness and fitness apps. Many hundreds of
smartphone apps for health consumers focus on
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16. IV. The Market for Smartphones and Health:
Some Barriers
aCCording to a priCewaterHouse C oopers Where is the patient in the app? Too much
survey, one-half of U.S. health consumers are willing app development is done by technologists,
to engage in online care and consultation with seemingly without much user input. “In an hour-
clinicians over a phone. Only one-quarter prefer to long presentation by a major telecoms company
stick with the traditional delivery model (Figure 7). at an mHealth conference, the word ‘patient’ was
Some market forces foster adoption of mobile not mentioned once,” observed Rob Havasy of the
health technologies, and in particular smartphones; Center for Connected Health. In general, enterprise
however, several key barriers will slow the progress of developers see more potential for profits in hospitals
adoption. and physicians and not in the consumer segment.
As health apps proliferate in this early phase
Figure 7. Consumers Willing to Use Alternative of mobile health, “Too many health smartphone
Methods to Get Care, 2009 apps are ill-conceived,” observed B.J. Fogg, director
of Stanford’s Persuasive Computer Lab, who has
• Likely • Neither • Unlikely studied the role of technology in changing people’s
health behaviors. “They’re not going to change
Mobile device (text)
anybody’s behavior,” he said. Fogg’s advice is to
21% 23% 55%
“Put hot triggers in the path of motivated people.”
Patient-group medical appointment
Smartphone apps can do this very well — if properly
28% 29% 43%
designed and targeted to those people who truly
Retail clinic
36% 29% 34% want to engage in their health. It should be noted
Worksite clinic
that apps for people who are sick need to be
37% 27% 36% appropriately designed in order to be accepted in the
Clinical trail/research already complicated lives of these patients and their
46% 27% 26% caregivers.
Telephone consultation Driving the app economy. The payment
50% 27% 22% system and health stakeholder financing drive
Internet or other computer technology
much of the app economy. The result is that some
50% 24% 26%
app categories are well populated while others are
not. Conditions that are associated with products
Note: Segments may not add up to 100 percent due to rounding.
Source: Top 10 Health Industry Issues in 2010: Squeezing the Juice Out of Healthcare, such as pharmaceuticals, medical devices, and
PricewaterhouseCoopers, December 2009.
health plans — like diabetes — have the most apps.
Some are the creations of companies that stand
to gain from patients’ use of their products. An
app created by a drug company could benefit the
company, prescribers, and patients; for example, a
How Smartphones Are Changing Health Care for Consumers and Providers | 13

17. dosage calculator that applies only to a specific drug devices” under the FDA’s definition, although
prescribed for the patient could be useful. Whatever they are not currently regulated by the agency.
entity sponsors the development of a health app, the However, when smartphones connect to sensors
sponsorship should be transparent to the end user. and automatically collect patient data, the FDA
Shop till you drop. How can consumers may take on a regulatory role. In January 2010, the
efficiently locate a health app that will be useful to FDA advised software developer MIMvista that its
them? “Discoverability is a big issue,” asserted Brian imaging app for the iPhone would need to undergo
Dolan of MobiHealthNews. “It’s overwhelming to pre-market approval to gain marketing clearance.
enter an apps store and start a search.” The process This requires clinical trials, a process that is time-
by which consumers seek health apps is cumbersome. consuming and expensive. “If software is intended
Most of the health/fitness apps in the iTunes Store to provide cure, mitigation, treatment, or prevention
have relatively few reviews on which a consumer can of disease, then the FDA may consider it a medical
make an educated purchasing decision. “I haven’t device,” according to Ed Daniels of Point-of-Care
seen a lot of user communities focused on apps yet,” Partners. The “wild west” nature of the health apps
Dolan said. “This is also true on the clinician side.” store may be a recipe for FDA regulation toward the
Further, it is difficult to ascertain whether a particular objective of protecting consumer safety. “The FDA
app is new or an update incorporating learnings from may want to make an example out of one or two
users and more robust functionality. apps to remind everyone that the agency is paying
Caveat emptor, health app downloader. It is attention to health apps. ‘First, do no harm’ applies,”
difficult to distinguish the safe, medically credible said Daniels.
apps from the less-safe ones. “Anyone can create an Advertising as a business model. Presumably
app and put it in an app store, warned Dr. Joseph to protect its turf in the mobile ad space, Apple
Kim. “This is concerning.” He indicated that apps posted information on its iPhone developer Web site
with branded logos from a government agency (e.g., alerting developers about incorporating location-
CDC, FDA, or NIH) or academic institution (with based information (such as GPS) into apps. Apple
Mayo Clinic, Cleveland Clinic, Johns Hopkins, and warned that if such location-based information were,
the University of Maryland among the most active “to enable mobile advertisers to deliver targeted ads
health app sponsors) are some of the most credible based on a user’s location,” the app would not be
apps for consumers to download for personal use. accepted by the iTunes Store.
Downloading an app doesn’t make you a Size and wiring matter. Mobile health solutions
doctor. Consumers who are very technology-savvy will help providers and institutions manage care in
may choose to download medical apps developed for lower-cost settings, and extend scarce resources from
health professionals. These consumers may believe expensive digital imaging hardware to expert clinical
that the downloading and use of medical apps is a specialists and visiting nurses. Larger institutions that
replacement for consulting a physician. However, are well staffed and use electronic medical records
there is a difference between participatory health and will be in a good position to adopt mobile health
practicing medicine. tools. But, “even we struggle,” acknowledged Rob
The looming presence of the FDA. It is not Havasy of the Center for Connected Health, part
clear whether health and medical apps are “medical of the large Partners Health System in Boston. “For
14 | C alifornia H ealtH C are f oundation

18. smaller hospitals, it will be that much harder when Figure 8. Medical Students Who Own Mobile Device,
by Brand, 2009
their staffs aren’t as used to using EMRs and CPOE.”
Physician practice workflow. With the advent
of HIT stimulus money incentivizing hospitals iPhone/iPod Touch
45%
and providers to adopt EHRs, physician practices
Palm PDA
will become more digitized. The biggest challenge
15% 29% 43 %
to physicians, according to Dr. Joseph Kim, will
Palm Smartphone
be, “How will smartphones get integrated into the 12% 29 % 43 %
workflow of physician practices? Does a physician
Blackberry
adopt a smartphone or an in-between computer 12% 29 % 43 %
and phone like an iPad or tablet device? All of these WinMobile
are useful digital interfaces.” Dr. Ted Eytan noted 7% 29 % 43 %
that physician practices will be asking how mobility PPC
can help them perform better for their patients. 6% 29 % 43 %
If a practice is a more mature user of EHRs, he Other
8% 29 % 43%
added, then mobility will be as much about patient
workflow as doctor workflow.
For new doctors, the transition will be smoother. Source: Epocrates survey, July 2009.
Some medical schools now issue smartphones:
Georgetown, The University of Louisville, and Ohio
State University are among the schools that require As reimbursement models for physicians move
students to use one. Today’s medical students are toward bundling and patient-centered medical
“digital natives,” so using a smartphone at the point- homes, there will be greater incentives for doctors
of-care comes naturally. As of July 2009, among and patients to partner in leveraging health
medical students who did not have a smartphone, information technology — including smartphones.
50 percent planned to buy one within the year; Privacy and security. Keeping personally
59 percent of these planned to acquire an iPhone identifiable health information secure is a long-
or iPod touch, and 21 percent planned on buying a standing challenge. The advent of mobile health
Blackberry.24 See Figure 8. requires strong encryption and strong authentication.
Participatory health. Patients, charged with Nonetheless, more patients are recognizing the
paying more for health care and making more value of digital health records. Researchers at some
clinical decisions for their and their families’ care, of Boston’s most prestigious medical institutions
have begun to adopt technology-based tools to recently found that, “especially for the chronically
enable deep health engagement. Most Americans and acutely ill, privacy is of far less concern to
now turn to the Internet to seek health information, patients than to health professionals.”25
and at least 50 percent of Americans would like to
email a physician to communicate about conditions,
appointments, prescriptions, and test results. See
Figure 9 on the following page.
How Smartphones Are Changing Health Care for Consumers and Providers | 15

19. Figure 9. Consumers Interested in Email Communication with Their Doctor, 2009
Schedule an appointment
8%
51%
44%
8%
Ask a question about a new condition
20%
38%
48%
7% • Online Chat
• Doctor’s Web Site
Ask a question about an existing condition • Email
20% • Text
37%
50%
8%
Update doctor on an existing condition
17%
38% %
51%
8%
Confirm an appointment
8%
45% %
53%
14%
Request a repeat Rx
10%
48% %
53%
11%
Receive test results
7%
32% %
59%
9%
None of these
73%
42%
31%
79%
Source: Consumers Would Embrace Email Communication with Their Doctor, Lightspeed Research, September 2009.
16 | C alifornia H ealtH C are f oundation

20. V. Looking Forward: Insights from the Early
Adoption Phase
u ltimately , smartpHone teCHnology Table 2. Mobile Platforms Used for Health, 2009
is only as important as its ability to empower users M o bI l E DEvI CE HEAlTH ExAM Pl ES
to communicate and collaborate in the interests Activity detector Wellcore Activity Monitor
of health. The technologies are changing quickly Cell phone TellMe Networks — text message
reminders for medication adherence
in terms of hardware platforms, software, and (Microsoft)
connectivity. New Bluetooth standards will make
Messaging FrontlineSMSMedic — private, two-way
phone devices for consumers cheaper and easier to platform network using open source software
use in 2011. When 4G (fourth generation) wireless and cell phones
devices enter the market, smartphones will further Motion sensor FitBit, Nintendo Wii
mature and take on more robust functionality. Pager ALRT Technologies’ Constant Health
Companion — prescription alert device
Augmented reality software will enable smartphones
to interact with the real world. And cell phones PDA MEDLINE Database on Tap, NLM Mobile,
LabNotes
will morph into smartphones as their software
Mobile Personal MobiWatch M-PERS
incorporates more advanced functions and adopts Emergency
open source mobile operating systems such as Response System
Android. The smartphone is but one platform among Senior phone Jitterbug
a growing array of mobile health devices, as Table 2 Smartphone iPhone health apps — sensors for
illustrates. diagnostics, such as glucose monitoring
The early adoption phase of smartphone apps in Medical-specific Implantable diagnostics — including
platforms patient vitals monitor, smart pills,
health provides some insights for health information wearable diagnostics, wireless pillbox
technology use in general, and apps in particular.
Source: “Adapted from TripleTree LLC,” Wireless & Mobile Health, 2009
Low financial threshold. Smartphone apps do
not require large up-front investments from health
providers or consumers. There is a low barrier to
entry. Apps are simple to adopt, pilot, and either an attractive “in-between” small device for health
continue to use if found valuable or abandoned. This providers, but as of April 2010, it is too early to
is important at a time when health providers’ access forecast.
to capital is highly constrained and when return- Respect the universal platform. The White
on-investment for big-dollar HIT projects is often House launched the program Text4Baby
difficult to measure or too low to justify. (www.text4baby.org) in February 2010. It aims to
Small is beautiful. Smartphones are about the promote maternal and child health in the United
size and shape of a prescription pad, a medium that States, where the infant mortality rate ranked 30th
doctors have long experience pulling out of a pocket among 31 developed countries in 2008.26 The
and recording on. A desktop or laptop computer program is a public-private partnership between
is far more cumbersome. The iPad may emerge as several U.S. government agencies, health care
How Smartphones Are Changing Health Care for Consumers and Providers | 17

21. companies, academic institutions, and virtually all good decisions at the moments they are made, from
of the major telecommunications network providers, nutrition choices to shopping for healthy foods and
who are waiving fees for these text messages. To move tracking steps.
the needle on public health, it is important to choose Still a wireless divide for the most vulnerable.
a platform that is universal. Today, that ubiquitous While cell phones are fairly ubiquitous in the U.S.
platform would be cell phones and not smartphones. across socioeconomic strata, smartphones are not
But in a matter of years, not decades, feature phones yet, and wireless connectivity isn’t evenly distributed,
will fast morph into “smart-erphones.” For large either. B.J. Fogg observed, “If a county health
health plans, health systems, and payers, smartphone department rolled something out on smartphones,
health apps can be deployed in targeted population it could be discriminatory. Any agency that builds
health programs. Consider Kaiser’s My Health a health program on a smartphone would battle the
Manager, used by 3 million members: Even if digital divide.” Therefore, in the short term, Fogg
10 percent of Kaiser’s EHR users have smartphones, recommends that mobile health programs be built
this represents 300,000 patients. for cell phones using text. “Virtually everyone has a
EHRs as smartphone apps. The killer app for cell phone, and everyone can text. It’s here and now,
physicians on smartphones could be electronic health if you’re going to do an intervention that reaches
records adoption. One of the major announcements the masses.” When Dr. Richard Katz of the George
at HIMSS 2010 was Epocrates’ development of an Washington Medical Center partnered with WellDoc
iPhone- and Web-based electronic health record. on a mobile health solution for patients with
One in three U.S. physicians has an Epocrates app diabetes, he found that only a handful of patients
loaded on a smartphone or other handheld device. among the 700 had a smartphone with the right plan
Functions might include a prescription app, an over- for the study. “This is why so much of what we do
the-counter information app, or a medical calculator. with technology is home grown,” pointed out Rob
According to Epocrates, the average clinician Havasy.
uses one of its applications six times a day. Small The first generation of smartphone apps has
physician practices already using Epocrates products yielded value for consumers and clinicians who have
will probably be more receptive to adding onto their adopted them because they are agile, easy-to-use,
current applications than to switch to a new, untested hand-held, and mobile. These features have not been
IT partner for EHR adoption. the traditional hallmarks of health IT. They empower
“My office is where I am.” Physicians’ work is providers and patients on the go. The relatively
mobile, and smartphone apps can seamlessly fit into speedy disruption that apps have had on health
the workflow and increase productivity, which can providers and consumers is just the beginning of a
result in both opportunities for revenue enhancement “small is beautiful” phase of health care information
and greater job satisfaction. technology and delivery.
“My life is 24x7.” For people managing chronic Whatever comes next will undoubtedly build on
health conditions such as asthma, diabetes, heart the characteristics that have made smartphones so
disease, and GI issues, sound health management popular.
is rooted in making good health “micro-decisions”
every day. Health apps on a smartphone can bolster
18 | C alifornia H ealtH C are f oundation

22. Endnotes
1. Centers for Disease Control, National Center for Health 13. Bland, E. “Cough Into Your Cell Phone, Get Diagnosis,”
Statistics. “Electronic Medical Record/Electronic Health Discovery News. November 8, 2009, news.discovery.com/
Record Use by Office-based Physicians: United States, tech/cough-cell-phone-diagnosis.html.
2008 and Preliminary 2009,” December 2009. 14. Ibid.
2. ChangeWave Research. “New Survey Shows Android OS 15. Choudhri AF, et al. Handheld Device Review of
Roiling the Smart Phone Market,” January 4, 2010. Abdominal CT for the Evaluation of Acute Appendicitis.
3. CNET news. “Smartphone market unfazed by recession,” RSNA 2009; Abstract SSE09-03.
November 6, 2009, news.cnet.com/8301-1035_3- 16. The Accreditation Council for Continuing Medical
10392252-94.html. Education (ACCME). ACCME®Annual Report Data 2008,
4. Hein K. Phones Top List of Most-Trusted Brands. www.accme.org/dir_docs/doc_upload/1f8dc476-246a-
Brandweek, October 17, 2009. Compared to other 4e8e-91d3-d24ff2f5bfec_uploaddocument.pdf.
consumer goods, wireless phone manufacturers have 17. Markle Foundation. Americans Overwhelmingly Believe
very loyal consumers — more loyal than any other brand Electronic Personal health Records Could Improve Their
category. Among smartphones, Apple’s iPhone has the Health, June 2008.
most loyal customers of any brand. In fact, six brands
of mobile phones fell in the top 30 of Americans’ most 18. Chilmark Research. iPHR Market Report, February 2010.
beloved brands as of September 2009. 19. Kripalani S, Xiaomei Y, Haynes RB. Interventions to
5. MobiHealthNews. “The World of Health and Medical Enhance Medication Adherence in Chronic Medical
Apps,” MobiHealthNews Research Report, February 2010. Conditions. Archives of Internal Medicine. 167(6):
540 – 549.
6. Horrigan J. “Wireless Internet Use.” Pew Internet &
American Life Project, July 2009. 20. Osterberg, L, Blaschke T. Adherence to Medication. New
England Journal of Medicine 353:487– 497.
7. TelecomEngine. “Statistics pointing towards continuing
dominance of SMS,” December 21, 2009. 21. National Consumers League. Prescription Medication
Adherence Provider and Patient Perspective Final Report,
8. See note 6. June 18, 2009.
9. Gartner. “Gartner Identifies the Top 10 Consumer Mobile 22. Research in Motion. The Blackberry Report: The National
Applications for 2012.” November 18, 2009, State of the Home Care Industry, October 10, 2009.
www.gartner.com/it/page.jsp?id=1230413.
23. Pena, V., A.J. Watson, J.C. Kvedar, and R.W. Grant.
10. Business Wire. “One in Five Physicians Likely To Purchase “Mobile Phone Technology for Children with Type 1 and
an iPad, More than 60 Percent Intrigued By New Device Type 2 Diabetes: A Parent Survey.” Journal of Diabetes
According to Epocrates Survey,” February 4, 2010, Science and Technology. Volume 3, Issue 6, November 2009.
www.businesswire.com/portal/site/home/permalink/?ndmview
id=news_view&newsId=20100204006741&newslang=en. 24. Epocrates. 4th Annual Future Physicians of America
survey, July 2009, www.epocrates.com/company/
11 Manhattan Research. “Physicians in 2012: The Outlook mediaroom/mediaresources/surveys/4th_fpasurvey.pdf.
for On Demand, Mobile, and Social Digital Media,”
October 2009. 25. Walker, J., D.K. Ahern, L.X. Le, and T. Delbanco.
“Insights to Internists: I Want the Computer to Know
12. Epocrates. “Brigham and Women’s Hospital Study Shows Who I Am,” Journal of General Internal Medicine, Volume
Doctors are Taking Action to Improve Patient Safety and 24, Number 6, June 2009, 727– 732.
Care,” December 9, 2005. www.epocrates.com/company/
news/10233.html. 26. Centers for Disease Control. “Behind International
Rankings of Infant Mortality: How the United States
Compares with Europe,” NCHS Data Brief, Number 23,
November 2009.
How Smartphones Are Changing Health Care for Consumers and Providers | 19

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